1
|
de Laurentis C, Pirillo D, Di Cristofori A, Versace A, Calloni T, Trezza A, Villa V, Alberti L, Baldo A, Nicolosi F, Carrabba G, Giussani C. Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature. Front Surg 2024; 11:1386887. [PMID: 38558881 PMCID: PMC10978771 DOI: 10.3389/fsurg.2024.1386887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background Recently, non-technical skills (NTS) and teamwork in particular have been demonstrated to be essential in many jobs, in business as well as in medical specialties, including plastic, orthopedic, and general surgery. However, NTS and teamwork in neurosurgery have not yet been fully studied. We reviewed the relevant literature and designed a mock surgery to be used as a team-building activity specifically designed for scrub nurses and neurosurgeons. Methods We conducted a systematic review by searching PubMed (Medline) and CINAHL, including relevant articles in English published until 15 July 2023. Then, we proposed a pilot study consisting of a single-session, hands-on, and cadaver-free activity, based on role play. Scrub nurses were administered the SPLINTS (Scrub Practitioners' List of Intraoperative Non-Technical Skills) rating form as a self-evaluation at baseline and 20-30 days after the simulation. During the experiment, surgeons and scrub nurses role-played as each other, doing exercises including a simulated glioma resection surgery performed on an advanced model of a cerebral tumor (Tumor Box, UpSurgeOn®) under an exoscope. At the end, every participant completed an evaluation questionnaire. Results A limited number of articles are available on the topic. This study reports one of the first neurosurgical team-building activities in the literature. All the participating scrub nurses and neurosurgeons positively evaluated the simulation developed on a roleplay. The use of a physical simulator seems an added value, as the tactile feedback given by the model further helps to understand the actual surgical job, more than only observing and assisting. The SPLINTS showed a statistically significant improvement not only in "Communication and Teamwork" (p = 0.048) but also in "Situation Awareness" (p = 0.031). Conclusion Our study suggests that team-building activities may play a role in improving interprofessional teamwork and other NTS in neurosurgery.
Collapse
Affiliation(s)
- Camilla de Laurentis
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - David Pirillo
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Andrea Di Cristofori
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Tommaso Calloni
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Andrea Trezza
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Valentina Villa
- Operating Room, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Lucia Alberti
- Operating Room, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angelo Baldo
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Federico Nicolosi
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
| | - Giorgio Carrabba
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Carlo Giussani
- School of Medicine and Surgery, Università Degli Studi di Milano Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| |
Collapse
|
2
|
Ziaei Darounkolaei N, Mousavi Kiasary SMS, Behzadi A, Nabavi Mosavi N, Ferdowsi SM. Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique. Front Vet Sci 2023; 10:1210089. [PMID: 37915948 PMCID: PMC10616265 DOI: 10.3389/fvets.2023.1210089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
Objectives To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain. Methods In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively. Results Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032). Conclusion Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.
Collapse
Affiliation(s)
- Navid Ziaei Darounkolaei
- Babol Branch, Department of Surgery and Radiology, Faculty of Veterinary Medicine, Islamic Azad University, Babol, Iran
| | - Seyed Mohamad Sadegh Mousavi Kiasary
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Amirhoushang Behzadi
- Babol Branch, Faculty of Veterinary Medicine, Islamic Azad University, Babol, Iran
| | - Niki Nabavi Mosavi
- Babol Branch, Department of Surgery and Radiology, Faculty of Veterinary Medicine, Islamic Azad University, Babol, Iran
| | | |
Collapse
|
3
|
Stefan P, Pfandler M, Kullmann A, Eck U, Koch A, Mehren C, von der Heide A, Weidert S, Fürmetz J, Euler E, Lazarovici M, Navab N, Weigl M. Computer-assisted simulated workplace-based assessment in surgery: application of the universal framework of intraoperative performance within a mixed-reality simulation. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000135. [PMID: 36687799 PMCID: PMC9853221 DOI: 10.1136/bmjsit-2022-000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/24/2022] [Indexed: 01/20/2023] Open
Abstract
Objectives Workplace-based assessment (WBA) is a key requirement of competency-based medical education in postgraduate surgical education. Although simulated workplace-based assessment (SWBA) has been proposed to complement WBA, it is insufficiently adopted in surgical education. In particular, approaches to criterion-referenced and automated assessment of intraoperative surgical competency in contextualized SWBA settings are missing.Main objectives were (1) application of the universal framework of intraoperative performance and exemplary adaptation to spine surgery (vertebroplasty); (2) development of computer-assisted assessment based on criterion-referenced metrics; and (3) implementation in contextualized, team-based operating room (OR) simulation, and evaluation of validity. Design Multistage development and assessment study: (1) expert-based definition of performance indicators based on framework's performance domains; (2) development of respective assessment metrics based on preoperative planning and intraoperative performance data; (3) implementation in mixed-reality OR simulation and assessment of surgeons operating in a confederate team. Statistical analyses included internal consistency and interdomain associations, correlations with experience, and technical and non-technical performances. Setting Surgical simulation center. Full surgical team set-up within mixed-reality OR simulation. Participants Eleven surgeons were recruited from two teaching hospitals. Eligibility criteria included surgical specialists in orthopedic, trauma, or neurosurgery with prior VP or kyphoplasty experience. Main outcome measures Computer-assisted assessment of surgeons' intraoperative performance. Results Performance scores were associated with surgeons' experience, observational assessment (Objective Structured Assessment of Technical Skill) scores and overall pass/fail ratings. Results provide strong evidence for validity of our computer-assisted SWBA approach. Diverse indicators of surgeons' technical and non-technical performances could be quantified and captured. Conclusions This study is the first to investigate computer-assisted assessment based on a competency framework in authentic, contextualized team-based OR simulation. Our approach discriminates surgical competency across the domains of intraoperative performance. It advances previous automated assessment based on the use of current surgical simulators in decontextualized settings. Our findings inform future use of computer-assisted multidomain competency assessments of surgeons using SWBA approaches.
Collapse
Affiliation(s)
- Philipp Stefan
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Informatics, Technical University of Munich, München, Germany
| | - Michael Pfandler
- Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig Maximilians University Munich, München, Germany
| | - Aljoscha Kullmann
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Informatics, Technical University of Munich, München, Germany
| | - Ulrich Eck
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Informatics, Technical University of Munich, München, Germany
| | - Amelie Koch
- Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig Maximilians University Munich, München, Germany
| | - Christoph Mehren
- Spine Center, Schön Klinik München Harlaching, München, Germany,Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria
| | - Anna von der Heide
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Campus Grosshadern, Ludwig Maximilians University Munich, München, Germany
| | - Simon Weidert
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Campus Grosshadern, Ludwig Maximilians University Munich, München, Germany
| | - Julian Fürmetz
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Campus Innenstadt, Ludwig Maximilians University Munich, München, Germany
| | - Ekkehard Euler
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Campus Innenstadt, Ludwig Maximilians University Munich, München, Germany
| | - Marc Lazarovici
- Institute for Emergency Medicine and Management in Medicine (INM), University Hospital, Ludwig Maximilians University Munich, München, Germany
| | - Nassir Navab
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Informatics, Technical University of Munich, München, Germany
| | - Matthias Weigl
- Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig Maximilians University Munich, München, Germany,Institute for Patient Safety, University of Bonn, Bonn, Germany
| |
Collapse
|
4
|
Gongola A, Gowen JT, Reif RJ, Thrush CR, Newhart H, Peckham M, Schwartz Z, Davies D, Kimbrough MK. Anatomy Scholars Program for Medical Students Entering a Surgical Residency. MEDICAL SCIENCE EDUCATOR 2021; 31:1581-1585. [PMID: 34603832 PMCID: PMC8446142 DOI: 10.1007/s40670-021-01352-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 05/25/2023]
Abstract
A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.
Collapse
Affiliation(s)
- AlleaBelle Gongola
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Jared T. Gowen
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Rebecca J. Reif
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Carol R. Thrush
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Hamilton Newhart
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Molly Peckham
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Zachary Schwartz
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - David Davies
- Department of Neurobiology & Developmental Science, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | | |
Collapse
|
5
|
Unberath M, Gao C, Hu Y, Judish M, Taylor RH, Armand M, Grupp R. The Impact of Machine Learning on 2D/3D Registration for Image-Guided Interventions: A Systematic Review and Perspective. Front Robot AI 2021; 8:716007. [PMID: 34527706 PMCID: PMC8436154 DOI: 10.3389/frobt.2021.716007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Image-based navigation is widely considered the next frontier of minimally invasive surgery. It is believed that image-based navigation will increase the access to reproducible, safe, and high-precision surgery as it may then be performed at acceptable costs and effort. This is because image-based techniques avoid the need of specialized equipment and seamlessly integrate with contemporary workflows. Furthermore, it is expected that image-based navigation techniques will play a major role in enabling mixed reality environments, as well as autonomous and robot-assisted workflows. A critical component of image guidance is 2D/3D registration, a technique to estimate the spatial relationships between 3D structures, e.g., preoperative volumetric imagery or models of surgical instruments, and 2D images thereof, such as intraoperative X-ray fluoroscopy or endoscopy. While image-based 2D/3D registration is a mature technique, its transition from the bench to the bedside has been restrained by well-known challenges, including brittleness with respect to optimization objective, hyperparameter selection, and initialization, difficulties in dealing with inconsistencies or multiple objects, and limited single-view performance. One reason these challenges persist today is that analytical solutions are likely inadequate considering the complexity, variability, and high-dimensionality of generic 2D/3D registration problems. The recent advent of machine learning-based approaches to imaging problems that, rather than specifying the desired functional mapping, approximate it using highly expressive parametric models holds promise for solving some of the notorious challenges in 2D/3D registration. In this manuscript, we review the impact of machine learning on 2D/3D registration to systematically summarize the recent advances made by introduction of this novel technology. Grounded in these insights, we then offer our perspective on the most pressing needs, significant open problems, and possible next steps.
Collapse
Affiliation(s)
- Mathias Unberath
- Advanced Robotics and Computationally Augmented Environments (ARCADE) Lab, Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
| | | | | | | | | | | | | |
Collapse
|
6
|
Schreyer J, Koch A, Herlemann A, Becker A, Schlenker B, Catchpole K, Weigl M. RAS-NOTECHS: validity and reliability of a tool for measuring non-technical skills in robotic-assisted surgery settings. Surg Endosc 2021; 36:1916-1926. [PMID: 33844085 PMCID: PMC8505574 DOI: 10.1007/s00464-021-08474-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/26/2021] [Indexed: 12/24/2022]
Abstract
Background Non-technical skills (NTS) are essential for safe surgical practice as they impact workflow and patient outcomes. Observational tools to measure operating room (OR) teams’ NTS have been introduced. However, there are none that account for the specific teamwork challenges introduced by robotic-assisted surgery (RAS). We set out to develop and content-validate a tool to assess multidisciplinary NTS in RAS. Methodology Stepwise, multi-method procedure. Observations in different surgical departments and a scoping literature review were first used to compile a set of RAS-specific teamwork behaviours. This list was refined and expert validated using a Delphi consensus approach consisting of qualitative interviews and a quantitative survey. Then, RAS-specific behaviours were merged with a well-established assessment tool on OR teamwork (NOTECHS II). Finally, the new tool—RAS-NOTECHS—was applied in standardized observations of real-world procedures to test its reliability (inter-rater agreement via intra-class correlations). Results Our scoping review revealed 5242 articles, of which 21 were included based on pre-established inclusion criteria. We elicited 16 RAS-specific behaviours from the literature base. These were synthesized with further 18 behavioural markers (obtained from 12 OR-observations) into a list of 26 behavioural markers. This list was reviewed by seven RAS experts and condensed to 15 expert-validated RAS-specific behavioural markers which were then merged into NOTECHS II. For five observations of urologic RAS procedures (duration: 13 h and 41 min), inter-rater agreement for identification of behavioural markers was strong. Agreement of RAS-NOTECHS scores indicated moderate to strong agreement. Conclusions RAS-NOTECHS is the first observational tool for multidisciplinary NTS in RAS. In preliminary application, it has been shown to be reliable. Since RAS is rapidly increasing and challenges for effective and safe teamwork remain at the forefront of quality and safety of surgical care, RAS-NOTECHS may contribute to training and improvement efforts in technology-facilitated surgeries. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08474-2.
Collapse
Affiliation(s)
- Julia Schreyer
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany. .,Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany.
| | - Amelie Koch
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany
| | - Annika Herlemann
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Armin Becker
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Boris Schlenker
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Institute for Patient Safety, University Hospital, Bonn University, Bonn, Germany
| |
Collapse
|
7
|
Mehren C, Korb W, Fenyöházi E, Iacovazzi D, Bernal L, Mayer MH. Differences in the Exposure of the Lumbar Nerve Root Between Experts and Novices: Results From a Realistic Simulation Pilot Study With Force Sensors. Global Spine J 2021; 11:224-231. [PMID: 32875893 PMCID: PMC7882829 DOI: 10.1177/2192568220917369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Nonrandomized prospective trial. OBJECTIVE Several studies could demonstrate "learning curves" in almost every single surgical procedure for unexperienced surgeons. This is in sharp contrast to the rising quality requirements in public health care to provide surgical training at patients "expense." The aim of this study was to visualize, measure, and set a baseline of the pressure load on the spinal nerve root during a simulated microdiscectomy on a standardized and validated model (RealSpine) under the influence of the level of surgical experience and individual skills. METHODS Five highly experienced spine surgeons and 5 trainees without considerable surgical experience were selected to perform a standardized microsurgical discectomy on a validated RealSpine simulator. Force-torque sensors were integrated in this simulator to measure the load on the nerve root. The forces were recorded every 125 ms. RESULTS We could identify cumulative for the total intervention as well as for defined single surgical steps of this procedure and as well in between the single subjects a significant higher tension and contusion forces on the nerve for the trainee group (Δp contusion 83-765 Nċs and Δp tension 159-1131 Nċs for the trainees. Δp contusion 16-171 Nċs and Δp tension 27-146 Nċs for the experts). CONCLUSION We could measure a difference between unexperienced and experienced surgeons regarding the manipulations of the nerve root during a standardized simulated microdiscectomy. This possibility could be the starting point for a new and innovative surgical education to improve outcome without negative side effects of "learning curves."
Collapse
Affiliation(s)
- Christoph Mehren
- Schön Klinik München Harlaching, Spine Center, Munich, Germany,Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria,Christoph Mehren, Schön Clinic Munich Harlaching, Harlachinger Straße 51, 81547 Munich, Germany.
| | - Werner Korb
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany,Vocationeers Salzburg, Hallein, Austria
| | - Esther Fenyöházi
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Davide Iacovazzi
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Luis Bernal
- Innovative Surgical Training Technologies (ISTT), University of Applied Sciences (HTWK), Leipzig, Germany
| | - Michael H. Mayer
- Schön Klinik München Harlaching, Spine Center, Munich, Germany,Academic Teaching Hospital and Spine Research Institute, Paracelsus Medical University, Salzburg, Austria
| |
Collapse
|